GP & PHCRED Conference July 2005

Australian Primary Health Care Research Institute

Nicholas Glasgow

Aims

By the end of this session:• Reflected more on the nexus between evidence and

policy• Clearer about APHCRI’s focus and approach• Had opportunity to ask questions

Overview

Professor Nicholas Glasgow• Overview of the research evidence and policy

Mr Robert Wells• Research Evidence and Policy – Reflections on a career

Dr Bev Sibthorpe• Research Evidence and Policy - Case studies

Professor Nicholas Glasgow• Research Evidence and Policy – The Evidence and APHCRI’s

Response Professor Jonathan Lomas

• Commentary

Where am I?

You’re 30 metres

above the ground in a

balloon

You must be a

researcher

Yes. How

did you know?

Because what you told me is

absolutely correct but completely

useless

You must be a policy

maker

Yes, how did

you know? Because you

don’t know where you are, you

don’t know where you’re going, and

now you’re blaming me

The problem

GP & PHC Research activity

Welcome announcement by Parliamentary Secretary to the Minister for Health and Ageing, Christopher Pyne for continued support of PHCRED

Increasing research and evaluation activity• Growth of this conference• PHCRED activities• RACGP developments• Success in competitive grant rounds such as NHMRC

APHCRI• Primary health system level focus• Policy relevance important• Complex (non linear) relationships between evidence and policy

How do we engage with this complexity?

Use of Research Evidence by Policy Makers

Nicholas Glasgow

Method

Comprehensive search of the black and grey literature relating to research dissemination, uptake and utilisation in primary health care policy

Supplemented by personal communications with key contributors to this literature including: • Professor Jonathan Lomas at the Canadian Health

Services Research Foundation• Professor John Lavis and • Professor Nicholas Mays

Relevant systematic reviews were identified

Method

A publication was judged to be a systematic review if there were explicit statements within the paper which:• articulated the question• clearly summarised the strategy used to identify relevant

studies• indicated how the identified studies were assessed for

inclusion/exclusion• summarised and synthesized the results

Greenhalgh AT, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of Innovations in Service Organisations: Systematic Review and Recommendations Milbank Quarterly 2004; 82: http://www.milbank.org/quarterly/8204feat.html (Accessed April 2005)

July 2005 SupplementJ Health Services Research & Policy

• Synthesizing evidence for management and policy-making

• Volume 10 Number 3 Supplement July 2005

• http://select.ingentaconnect.com/rsm/13558196/v10n3x1/contp1-1.htm

Key review before the supplement

Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers perceptions of their use of evidence: a systematic review J Health Serv Res Policy 2002; 7:239-244h

Facilitators• Personal contact between researchers and policy makers• Timeliness and relevance of the research• Research that included a summary and clear recommendations• Good quality research• Research that confirmed current policy or endorsed self-interest• Community pressure or client demand for research• Research that included effectiveness data

Barriers• Absence of personal contact between researchers and

policy-makers• Lack of timeless or relevance of research• Mutual distrust, including perceived political naivety or

scientists and scientific naivety by policy-makers• Power and budget struggles• Poor quality research• Political instability and high turnover of policy-making

staff

A policy maker reflects on evidence and policy

Mr Robert Wells

Policy

Evidence-based Rational process Balancing of interests Long term perspective Open & accountable Objectively evaluated

Reactive Ad hoc responding to specific

interests Short term horizon Secretive Spin

Research

Systematic Methodical Accurate Objective Analytical Detailed

Curiosity driven Irrelevant Slow Technical Narrowly focussed

A researcher reflects – case studies from APHCRI

Dr Bev Sibthorpe

Key review before the supplement

Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers perceptions of their use of evidence: a systematic review J Health Serv Res Policy 2002; 7:239-244h

Facilitators• Personal contact between researchers and policy makers• Timeliness and relevance of the research• Research that included a summary and clear recommendations• Good quality research• Research that confirmed current policy or endorsed self-interest• Community pressure or client demand for research• Research that included effectiveness data

APHCRI’s approach

Professor Nicholas Glasgow

Overview

Getting past “two communities” What is evidence? What does “use” of evidence mean? How do systematic reviews and synthesis fit in? What does APHCRI see as an applied research

cycle? What does this mean for APHCRI's work?

Australian Government

Policy and Decision Makers

Providers of Primary Health Care services

and their organisations

Research Community

Consumers of Primary Health Care Services

and their organisations

APHCRI

Hub and Spokes

Key Stakeholders (“communities”)

Getting past “two communities”

The nature of “evidence”

“Research” and “evidence” are words that are value laden and differently understood

What is being sought is valid and reliable knowledge, and wisdom in its application

If innovations within primary health care are going to be conceived, tested and implemented there must be willingness on the part of all players to understand research and evidence through different lenses

Helpful insights will be derived from different research traditions.*

*Greenhalgh AT, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of Innovations in Service Organisations: Systematic Review and Recommendations Milbank Quarterly 2004; 82: http://www.milbank.org/quarterly/8204feat.html (Accessed April 2005)

The nature of “use”

Direct (engineering, instrumental) use• Research feeds directly into decision making for policy and practice

Symbolic use (mobilisation of support)• to add weight to a particular policy direction• an instrument for persuasion. Findings – or simply the act of research – can be used

as a political tool and can legitimate particular courses of action or inaction Conceptual use (enlightenment)

• Even if policy makers or practitioners are blocked from using findings, research can change their understanding of a situation, provide new ways of thinking and offer insights into the strengths and weaknesses of particular courses of action. New conceptual understandings can then sometimes be used in instrumental ways.

Wider influence• influence beyond the institutions and events being studied. Evidence may be

synthesised. It might come into currency through networks of practitioners and researchers, and alter policy paradigms or belief communities

Nutley S, Davies H, Walter I. Evidence Based Policy and Practice: Cross Sector Lessons From the UK. ESRC UK Centre for Evidence Based Policy and Practice: Working Paper 9. 2002. ESRC UK Centre for Evidence Based Policy and Practice; Research Unit for Research Utilisation

Systematic reviews and synthesis

Cogent argument for systematic reviews to be given greater profile as evidence of value to policy makers

There is an emerging science of systematic reviews and synthesis

*Lavis JN, Davies HTO, Oxman A, Denis JL, Golden-Biddle K, Ferlie E. Towards Systematic Reviews That Inform Healthcare Management and Policymaking JHSRP 2005; v10 Number 3 Supplement

*Lavis JN, Posada FB, Haines A, Osei E. Use of research to inform public policymaking Lancet 2004; 364: 1615-21

Economic assumptions

How you pay (reward) people contains incentives to do (or not do) particular things

Economists speak of the need to align incentives to ensure that that inherent incentives encourage the behaviour needed to achieve desired goals

Are producers of research evidence rewarded for addressing policy questions?

Pre Research•Priority setting/review

•Questions

• Methodologies

• Funding

• Research training (not just researchers)

Research

•Primary

•Secondary

Evaluation Adoption(Use

•Direct

•Symbolic

•Enlightenment)

Dissemination

Australian Government

Policy and Decision Makers

Providers of Primary Health Care services

and their organisations

Research Community

Consumers of Primary Health Care Services

and their organisations

APHCRI

Hub and Spokes

Key Stakeholders

Who’s question(s)?

Policy makers and decision makers in both the Commonwealth and States/Territories;

Providers of primary health care services and the various organisations with which they are linked;

Researchers; and/or Users of primary health care services and the

various organisations with which they are linked

Aim for Stream Four

“to systematically identify, review, and synthesise knowledge about primary health care organisation, funding, delivery and performance and then consider how this knowledge might be applied in the Australian context”

Seven Topic Areas

1. Chronic disease management;2. Integration, co-ordination and multidisciplinary care;3. Prevention and early intervention;4. Innovative models for comprehensive primary health care

delivery;5. Innovative models for the management of mental health in

primary health care settings;6. Older Australians and health promotion, prevention and

post-acute care; and7. Children and young Australians, health promotion and

prevention

APHCRI questions within topics

Questions of two general types • “What do we know about….?” and • “What are the possible options?”

The “What do we know about…?” questions are the focus of the systematic review and synthesis, while the “What are the possible options?” questions build on the results to develop ways forward for Australia’s primary health care system

APHCRI is interested in specific questions being addressed in each topic area, including questions about funding arrangements (existing and alternative), delivery arrangements and governance arrangements, and performance - i.e. system level questions

Why Stream Four?

This systematic processing of knowledge will provide:• A strong basis on which national primary health care policy can be

informed,• Clear insights into important knowledge gaps, and • The foundation on which APHCRI can build subsequent streams of

activity

The process for Stream Four will:• Strengthen the hub and spoke model – we mean it!• Build capacity in the policy and research communities with regard to

primary health care policy relevant research

Stream Four Workshops

Four workshops occur during Stream Four At least one CI from each group Attendance by members of the DoHA Allows

• Iteration of the questions• Reflection on the results as they start to emerge• New direction to occur• Researchers to focus on the research, policy analysts to focus on

policy analysis and both to learn more of the other

Miscommunication is real

ATTORNEY: Is your appearance here this morning pursuant to a deposition notice which I sent to your attorney?

WITNESS: No, this is how I dress when I go to work.

ATTORNEY: What gear were you in at the moment of the impact?

WITNESS: Gucci sweats and Reeboks.

Professor Lomas Comments

END